Indications and findings of upper gastrointestinal endoscopy in patients presenting to a District Hospital, Ghana
Adwoa Agyei-Nkansah1, Amoako Duah2,&, Maite Alfonso2
1Department of Medicine and Therapeutics School of Medicine and Dentistry, College of Health Science, University of Ghana, P.O.BOX 4236, Korle-Bu, Accra, Ghana, 2St. Dominic Hospital, P.O.BOX 59, Akwatia, Ghana
Amoako Duah, St. Dominic Hospital, P.O.BOX 59, Akwatia, Ghana
Upper Gastrointestinal (UGI) symptoms are among the commonest complaints
for which patients seek medical attention. Characteristics of patients undergoing
UGI endoscopy (UGIE) at the district hospital in Ghana are largely unknown.
This study was to document the demographic characteristics, indications and
endoscopic findings of patients undergoing UGIE at the district hospital
this study used a cross-sectional design to consecutively recruit 371 patients referred to the Endoscopy Unit of the St. Dominic Hospital, Akwatia for UGIE. Demographic data and indications for the UGIE were recorded. Endoscopic findings per each participant were recorded. Helicobacter pylori (H. pylori) infection was confirmed by rapid-urease examination of gastric antral and body biopsies at endoscopy.
there were 159(42.9%) males out of the 371 patients. The age ranged from 4 to 94 years with a median age of 46 years. Dyspepsia was the commonest indication occurring in 282(76.0%) patients. The commonest endoscopic diagnosis was gastritis which occurred in 261(70.4%) patients. The prevalence of H. pylori obtained by immediate rapid-urease-campylobacter like- organism (CLO) test was 44.9%.
the main indication for UGIE in the studied patients was dyspepsia and most of these patients had gastritis on endoscopy. Only few patients had normal findings. The prevalence of H. pylori in this population was low compared with most of the previous studies done in the country. There is the need to establish more endoscopy centres within the district hospitals in the country and more health professionals trained to perform them.
Upper Gastrointestinal (UGI) symptoms are among the commonest complaints
for which patients seek medical attention, with the annual prevalence
of dyspepsia approximating 25% . Diseases associated
with dyspepsia are leading causes of gastrointestinal morbidity
and mortality globally. Peptic ulcer disease, gastroesophageal
reflux disease and cancers
affect millions of people worldwide . Gastrointestinal
endoscopy (UGIE) is one of the most commonly performed endoscopic
procedures and provides valuable information in patients with gastroduodenal
disorders. It gives
diagnostic yield over radiology particularly in the investigation
of upper gastrointestinal bleeding, inflammatory conditions of
the UGI track like
esophagitis, gastritis and duodenitis as well as the diagnosis
of Mallory Weiss tears and vascular malformations .
Appropriate diagnostic indications for UGIE include: evaluation of an upper abdominal
symptom that persists despite an appropriate trial of therapy,
upper abdominal symptoms associated with alarm features that have
been suggested as indicators
of high risk for a serious disease [4, 5].
These features include recent onset of dyspepsia in an older patient,
dysphagia, persistent vomiting, haematemesis/melena stools, anemia
and/or weight loss.
Other indications are diseases in which the presence of UGI pathology
might modify the management (e.g., patients who have a history
of ulcer or gastrointestinal
bleeding who are scheduled for organ transplantation, long-term
anticoagulant, or non-steroidal anti-inflammatory drug therapy
for arthritis and those
with cancer of the head and neck), familial adenomatous polyposis
coli syndrome, suspected neoplastic lesions, peptic ulcer, upper
or obstruction, gastrointestinal bleeding, caustic substance ingestion,
and evaluation of chronic diarrhea among others [6, 7].
UGIE has been found to be both effective and a relatively safe procedure that
can be performed at large medical centres, small rural hospitals,
outpatient clinics or even private offices . Establishing
causes of UGI diseases leads to more efficient treatment and consequently
morbidity and mortality rates. In Ghana, UGIE service is offered
in three teaching hospitals and a few other public or private centers,
all in the
cities. There are many reports in the literature on the indications
and findings of UGIE mainly from the teaching hospitals and few
private hospitals. However, scanty data are available from the
on the profile
of patients attending endoscopy unit for examination in this country.
This study aims to document the demographic characteristics, indications
endoscopic findings of patients undergoing UGIE at a district hospital
A formal approval of this study was obtained from the Ethical and
Protocol Committee of the University of Ghana School of Medicine
and Dentistry. This study was conducted in accordance with the Helsinki
study used a cross-sectional design to consecutively recruit medical
in-patients and clinic out-patients referred to the Endoscopy Unit of the
Hospital (SDH) with UGI symptoms for endoscopy, from 14th January,
2018 to 14th December, 2018. SDH was founded in 1960 and has
339 beds and is the district hospital of Denkyembour district,
Akwatia in eastern region of Ghana and the main referral centre for other
district hospitals. It offers a breadth of medical and surgical
services including gastroenterology and endoscopy. Study participant recruitment
and data collection was performed at the Endoscopy Unit, SDH, between
2018 and December 2018. The Endoscopy Unit is manned by a medical
gastroenterologist with the support of trained nurses and auxiliary staff.
It uses Olympus
and video endoscopy equipment for endoscopic procedures. It runs
endoscopy sessions twice per week and offers both upper and lower Gastrointestinal
(GI) endoscopy services. Each session performs approximately 5
and 1 lower GI endoscopy. Procedures performed are both diagnostic
and interventional. The latter include injection sclerotherapy and variceal
Medical in-patients and clinic out-patients with gastrointestinal symptoms referred
to the Endoscopy Unit, SDH were enrolled into the study. Study participants were
consecutively recruited each week from endoscopy unit. All patients were given
explanatory statements of the project and consented prior to endoscopy. Non-consenting
patients were excluded from the analysis. Demographic data of the patients were
taken including age, sex, occupation etc. Indications for the UGIE were recorded.
UGIE was performed using the Olympus CV-160 videoscope. Study participants were
given the option of sedation with (intravenous midazolam 2mg) or 10% lidocaine
(xylocaine) throat spray. H. pylori
infection was determined by the rapid-urease-campylobacter
organism (CLO) test on gastric antral and body biopsies at UGIE (specificity
sensitivity > 93%; Cambridge Life Sciences Ltd, Cambridge, UK). Endoscopic findings
per each participant were recorded. Statistical analysis was performed using
statistical software package. Results were expressed as
median and interquartile range for continuous variables and proportions for nominal
variables. The proportion of the major endoscopic findings was presented on a
95% confidence interval.
There were 159(42.9%) males out of the 371 patients. Their ages
ranged from 4 to 94 years with a median age of 46 years (Table
1). The 41-50
year age group had the highest frequency of 84(22.6%) patients,
followed by the 31-40 year age group with 64(17.3%) patients. Other
details of the
age distribution are shown in Figure
1. Dyspepsia was the commonest indication
occurring in 282(76.0%) patients followed by upper GI bleeding
symptoms (hematemesis and melena stools) representing 70(18.9%)
The major endoscopic diagnoses were gastritis which occurred in
261(70.4%) patients followed by duodenitis in 103(27.8%) patients,
gastric ulcer (40/371,
10.8%), normal findings (30/371, 8.1%), duodenal ulcer (25/371,
6.7%) and oesophageal varices (15/371, 4.0%) (Table
3). The prevalence of H. pylori
obtained by immediate CLO-testing of gastric antral and body biopsies
for 356 patients out of 371 was 44.9% (Table
1). Amongst the 278 dyspeptic patients,
gastritis was the commonest finding (212/278, 76.3%) followed by
duodenitis (92/278, 33.2%) (Table
This study aimed to document the demographic characteristics, indications
and endoscopic findings of patients undergoing UGIE at the district
hospital in Ghana. This study represents the first ever report
on UGIE indications and findings from a district hospital in Ghana.
involving UGIE among Ghanaian patients have all come from the teaching
hospitals and private hospitals in Accra, Kumasi and Tamale [9-13].
Dyspepsia was the commonest indication for upper GI endoscopy in
the vast majority of our participants. This is similar to studies
conducted in Ghana
and other West African and East African countries [12, 14-17].
Other reasons for UGIE among our patients were symptoms of UGI
bleeding, screening for oesophageal varices in cirrhotic patients
and recurrent vomiting.
Only 1.1% of our patients underwent upper GI endoscopy for dysphagia
which is similar to 1.0% reported by study done in Kumasi, Ghana
This differs from a study done in Malawi by Wolf et al. 
which reported dysphagia as the most common indication for UGIE.
Thirty seven percent (37%) of their patients had dysphagia as an
UGIE. The high prevalence of oesophageal cancer in Malawi may account
for this difference . Also endoscopy services are
restricted in Malawi and as such only patients with alarm symptoms
are referred for
upper GI endoscopy .
Gastritis was the most frequent endoscopic finding in our patients, followed
by duodenitis. This is comparable to previous Ghanaian studies [3
which reported gastritis and duodenitis as common endoscopic findings among their
patients. Gastric ulcer was diagnosed more frequently than duodenal ulcers among
our patient population and this is similar to the study conducted by Gyedu et
] in Kumasi. This is in contrast to the findings
of one study from Accra that reported more duodenal ulcers than gastric ulcers
]. This study was conducted mainly in a farming community
and most of them may abuse non-steroidal anti inflammatory drugs (NSAIDS) after
farm work. Many of the patients in this study were in their middle age or older
and probably on NSAIDS for degenerative joint and bone diseases which predispose
more to the development of gastric ulcers. Gastric perforations were more common
than duodenal perforations among the Kumasi population according to the study
by Ohene et al.
]. They also noted that patients
presenting with gastric perforations were more frequent users and abusers of
NSAIDS and herbal medicines or concoctions [20
]. The percentage
of oesophageal varices detected in this study was more than previous studies
published in this country [12
]. This is because as part
of the indications for endoscopy, patients with liver cirrhosis without bleeding
were referred for endoscopy in this study. Normal findings in this study were
far lower than earlier studies that have been published in this country [3
The difference may probably be due to improved endoscopic techniques in identifying
UGI pathology or improve methods in clinical diagnosis over the decade or may
be as a result of scarce availability of endoscopy services so people are referred
appropriately for endoscopy. The use of Proton Pump Inhibitor (PPI) and NSAID
could also modify the findings of endoscopy and information about this was not
available in all the studies.
colonization of the gut is one of the most common infections globally. Some researchers described it as the most common chronic human bacterial infection [21
]. It is the main cause of chronic gastritis and the principal etiological agent of gastric cancer and peptic ulcer disease. In many countries, the incidence of H. pylori
has been decreasing in association with improved standard of living and improved portent antibiotics. The prevalence of H. pylori
in this study was 44.9%. This is comparable to 45.2% reported by Darko et al.
], but in contrast to 74.8% reported by Archampong et al.
], in the country. Other previous studies in Ghana [24
], Nigeria [25
] and other developing countries [26
] have also reported high prevalence of H. pylori
. Possible reasons for this difference may be the increasing effective eradication therapy of the infection with antibiotic combination and proton pump inhibitors (PPI) and also the widespread and indiscriminate use of antibiotics and PPI. This study did not exclude patients who were already on antibiotics and PPI or have taken these drugs prior to the study. It may also be associated with improved sanitation among the inhabitants [27
]. Despite the decrease in prevalence of H. pylori
among patients in this study, the current prevalence of 45.2% is still high compared to rates in developed countries [28
]. The prevalence of H. Pylori
infection is associated with lower socioeconomic status, sanitation, basic hygiene, poor diet; overcrowding, ethnicity, gender and age, low levels of education and geographic location also play a major role in the distribution of the infection [29
]. This may explain the higher prevalence of H. Pylori
in developing countries.
The commonest indication for UGIE in the studied patients from a district hospital in Ghana was dyspepsia and most of these patients had gastritis on endoscopy. Only few patients had normal findings. Gastric ulcers were commoner than duodenal ulcers in this patient population. The prevalence of H. pylori in this population is low compared with most of the previous studies done in Ghana and other African countries. The outcomes of this study have implications for policy and planning. There is a need to identify the common causes of dyspepsia/gastritis in the community. This will help formulate and put in place community-based interventions including education to avoid these precipitating factors. There is also the need to establish more endoscopy centers in the district hospitals in this country and more health professionals trained to perform them.
What is known about this topic
- In many developing countries, the H. pylori infection has a high prevalence rate of 80-95%;
- Patients with dyspepsia in the absence of any other alarm symptoms are more likely to have normal endoscopic findings.
What this study adds
- The prevalence of H. pylori obtained in this district based study was 44.9%, far lower than prevalence of many studies conducted in Ghana and other Africa countries;
- Normal findings of patients with dyspepsia without any other symptoms in this study were far lower than earlier studies conducted on this subject.
The authors declare no competing interests.
Adwoa Agyei-Nkansah, the principal investigator of the project and
Amoako Duah were involved in concept design, patient recruitment, data analysis
and drafting of the manuscript. Maite Alfonso, assisted the principal investigator
and Amoako Duah in the analysis and interpretation of the data, critically
revised the article and provided final approval of the article.
I would like to acknowledge Dr. Rafiq Okine, for his assistance during analysis of project data. I am grateful to Rev. Sr. Georgina Jiaggey, Sethina Deblin Ashitei, and Bertha Narkie Nartey, endoscopy nurses of Saint Dominic Endoscopy Unit, for their assistance during patient recruitment and performance of the rapid-urease H. pylori-CLO-testing. Special appreciation also goes to Dr. med. Hans-Georg Jester for his immense contribution in the setting up of the SDH endoscopy unit and his continuous support in its operation.
Tables and figure
Table 1: demographic characteristics and Campylobacter-like organism (CLO test)
Table 2: indications of endoscopy
Table 3: primary endoscopy findings
Table 4: endoscopic findings of dyspeptic patients alone
Figure 1: age distribution of the study participants
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